Background: Lead continues to be a health hazard in the United States, especially in children, where it may lead to behavioral changes and developmental delay. Most exposures can be traced to the ingestion of a lead-containing substance, but cases of toxic lead levels developing in patients with retained bullets exist. There is no standard for lead foreign body removal, but it is generally accepted lead objects should be removed from synovial fluid and cerebrospinal fluid (CSF). We present the case of a child shot in the neck with an air pellet gun resulting in a lead pellet lodging in his cervical vertebrae, which represented a clinical dilemma.
Case Report: A 7 year-old boy presented after being shot in the neck with a lead pellet. Lead content was confirmed with the manufacturer. Surgical exploration revealed the pellet had penetrated the oropharynx and was firmly embedded in the C2 vertebrae at the base of the odontoid process. Extraction required a neurosurgeon and one was not immediately available. The serum lead concentration 24 hours post-exposure was 6 mcg/dL. A CT scan confirmed the pellet's location to be in the bone of C2 and not the intervertebral disc. As there were significant risks associated with surgical removal of the pellet, the medical toxicologists and neurosurgeons decided to leave it in place. Twenty days postexposure a repeat CT scan was unchanged. Ten months post-exposure the child had no signs or symptoms of lead toxicity; no more lead testing had been done due to non-compliance of the child's mother.
Discussion: Lead is common to firearm ammunition because it is cheap, malleable, and delivers a high amount of kinetic energy per volume. Toxic lead levels from retained bullets have only rarely been reported. Bullets that remain lodged in muscle or fat will typically become encapsulated in fibrous tissue, preventing systemic absorption. The literature lends more credence to concern for lead foreign bodies located in spaces such as the intervertebral discs and CSF. The case was unique because there was evidence of the pellet being encompassed by bone, but given the lead concentration 24 hours post-exposure there was a definite possibility of exposure to either a disc or CSF. The decision to leave the pellet in place was difficult and involved weighing both the toxicologic and surgical recommendations. Lead toxicity could still develop in this patient, and education and continued monitoring will be important.
Conclusion: The decision of whether or not to removed a lead foreign body in or around the vertebral column is a difficult one; toxicologic and surgical risks and benefits need to be weighed against one another. If not removed, there is a possibility for increased lead levels acutely and chronically.